Page 1 of 3 2/1/2017 Board Policy Manual Table of Contents

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1 Quinte Health Care Board of Directors Policies TABLE OF CONTENTS Part I: Establish Strategic Direction I-1 Vision, Mission and Core Values I-2 Strategic Planning I-3 Community Engagement (deleted June 2017) Part II: Provide for Excellent Leadership and Management II-1 II-2 II-3 II-4 II-5 II-6 II-7 II-8 II-9 II-10 Chief Executive Officer Selection and Succession Planning Chief Executive Officer Direction Summary Chief Executive Officer Job Description Chief Executive Officer and Chief of Staff Performance Management and Evaluation Compensation for Employees of the Board (CEO and COS) Expense Reimbursement and Travel Policy for Employees of the Board Occupational Health and Safety Accountability Framework Chief of Staff Direction and Job Description Chief of Staff Selection and Succession Planning Reporting on Compliance Part III: III-1 III-2 III-3 III-4 III-5 III-6 III-7 III-8 Ensure Program Quality and Effectiveness Quality Improvement and Safety Performance Monitoring Risk Management Ethics Respect for Diversity Privacy and Security of Information Complaints (Patient Care and Other) Physician Credentialing Page 1 of 3 2/1/2017 Board Policy Manual Table of Contents

2 Part IV: IV-1 IV-2 IV-3 IV-4 IV-5 IV-6 Ensure Financial and Organizational Viability Financial Objectives Financial Planning and Performance Asset Protection Approval and Signing Authority Borrowing Investment Policy Part V: Ensure Board Effectiveness 1. Governance Policy Framework V-A-1 Principles of Governance and Board Accountability V-A-2 Roles & Responsibilities of the Board of Directors V-A-3 Roles & Responsibilities of Elected or Ex-Officio Directors V-A-4 Director s Declaration V-A-5 Guidelines for the Selection of Directors V-A-6 Board Size and Composition (Reference By-Law No. 1 (Article 4.1) V-A-7 Board Standing and Ad Hoc Committees V-A-8 Position Description for the Board Chair V-A-9 Position Description for the Vice-chair V-A-10 Position Description for the Treasurer V-A-11 Position Description for the Board Secretary V-A-12 Position Description for a Standing Committee Chair V-A-13 Conflict of Interest [Reference By-Law No. 1 (Article 6.1)] Page 2 of 3 2/1/2017 Board Policy Manual Table of Contents

3 2. Governance Process V-B-1 Process for Nomination of Directors [Reference By-Law No. 1 (Article 4.8)] V-B-1.1 Advisory Council (deleted June 2017) V-B-2 V-B-3 V-B-4 V-B-5 V-B-6 V-B-7 V-B-8 V-B-9 V-B-10 V-B-11 V-B-12 V-B-13 V-B-14 Process for Selection of Board Officers Process for Nomination of Chair, Directors and Non-Director Members of Board Standing Committees Board Orientation Ongoing Board of Director Education Board Committee and Ad Hoc Committee(s) Principles (deleted) Board Goals Board Meetings Board and Individual Director Evaluation Receipt of Gifts by Individual Directors Board Member Recognition Reimbursement of Board Director Expenses Resignation and/or Removal of a Director Review of Board Policies Part VI: VI-1 VI-2 VI-3 VI-4 VI-5 VI-6 Build Relationships Relationships with Ministry of Health and Long-Term Care and Local Health Integration Networks Relationships with Other Health Services Providers and Key Stakeholders Build Relationships with the Municipal/County Councils Support and Relationship with Foundations Communications and Engagement Contributions and Lobbying Page 3 of 3 2/1/2017 Board Policy Manual Table of Contents

4 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Vision, Mission and Core Values Title: Vision Mission and Core Values Policy No: I-1 Original Issue Date: 2010 Manual: Board Last Reviewed: January 2017 Revision Date(s): January 2010 January 2012 Section: Part I Establish Strategic Direction Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board of Directors provides strategic leadership to Quinte Health Care in the establishment of and commitment to Quinte Health Care s Vision, Mission and Core Values. MISSION We are an integrated system of four hospitals working with our partners to provide exceptional care to the people of our communities. VISION QHC will provide exceptional and compassionate care. We will be valued by our communities and inspired by the people we serve. OUR VALUES Imagine it s you Respect everyone Take ownership We all help provide care Always strive to improve

5 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Strategic Planning Title: Strategic Planning Policy No: I-2 Original Issue Date: 2010 Manual: Board Last Reviewed: January 2017 Revision Date(s): September 2010 February 2013 Section: Part I Establish Strategic Direction Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors As per Policy V-A-2, the Board of Directors, in collaboration with the CEO and management team, is responsible to establish the strategic directions for Quinte Health Care. The Vision and Mission of Quinte Health Care provide the foundation upon which the strategic directions are developed. The Board will: Consider key stakeholders and health care needs and engage with the community served, the LHIN and other health service providers when developing plans and setting priorities for the delivery of hospital-based health care as required under the Local Health System Integration Act; Establish and periodically review and update QHC s mission, vision and values; Contribute to the development of and approve the strategic plan of QHC, ensuring that it is aligned with community need, MOHLTC policy, the LHIN integrated health services plan and promotes where appropriate interdependencies with other health service providers; Conduct a review of the strategic plan as part of a regular annual planning cycle; Monitor and measure corporate performance regularly against the approved strategic and operating plans and Board-approved performance metrics. 1. The Chief Executive Officer (CEO) is responsible to the Board for establishing the strategic planning process, for approval by the Board. The Board as a whole will engage with the CEO and senior leadership team in developing the strategic plan and monitoring it on an ongoing basis.

6 2. Once the strategic plan has been developed, everything the organization currently does, undertakes as new, or stops doing, will be measured against whether or not it advances the accomplishment of the strategic plan. 3. The organization s annual operating plan will ensure the advancement of the strategic plan by addressing annual corporate goals and objectives. The annual corporate goals and objectives will be set by the CEO with Board approval. 4. Annually, the Board will consider a review of the corporate goals and objectives prepared by the CEO. 5. On an annual basis, the Board of Directors will establish goals for the Board consistent with the Mission and Vision, the Strategic Plan of the organization, and key issues which are a priority for the Board in the coming year. 6. At its annual retreat, the Board will review the strategic plan and the progress being made toward its achievement. As necessary, the Board will direct management to augment/revise/update the plan to ensure it continues to support the achievement of the vision of Quinte Health Care. Regular monitoring and progress reports will be provided to the Board.

7 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Chief Executive Officer Selection and Succession Planning Title: Chief Executive Officer Selection and Succession Planning Policy No: II-1 Original Issue Date: 2010 Last Reviewed: November 2016 Manual: Board Revision Date(s): September 2010 March 2012 June 2014 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board will ensure that provision is made for continuity of leadership for the organization, and will have in place a documented process for succession should the CEO position become vacant due to sudden loss, resignation, retirement or termination. The succession plan will also specify the process for appointing an interim CEO, should the CEO require an extended leave of absence due to personal, health or other reasons. The CEO will report on the succession plan annually during the CEO evaluation process. 1. Sudden Vacancy (e.g. death, resignation, termination, extended leave) The CEO will identify to the Chair of the Board in writing at the beginning of each Board year which member of senior management is recommended to fill the role of interim CEO, if a sudden loss of the CEO occurs. The appointment of an interim CEO will be subject to approval by the Board. 2. Short Term Vacancy (e.g. out of county vacation) The CEO will identify which member of senior leadership will act in the capacity of Acting CEO during this short term absence. This selection shall be at the discretion of the CEO at the time of the absence. The CEO shall advise the Chair of the Board of the selection prior to departure 3. Planned Vacancy (e.g. retirement) The process to fill a planned vacancy will include: i) The CEO will be responsible for developing internal successors through succession planning and development ii) The Board will establish a CEO Search Committee consisting of five elected Directors and the Chief of Staff. Support for the Committee will be provided by the

8 Vice President responsible for Human Resources (HR) (If the Vice President responsible for HR is a candidate, then the chair of the committee will select another individual from management.) iii) The CEO Search Committee will be chaired by the Chair of the Board or a delegate appointed by the Chair. iv) The Search Committee may, at its discretion, select a search firm to assist with the process. The Search Committee will interview a short list of candidates and recommend to the Board their candidate of choice. v) In the event that a new CEO has not been appointed prior to the departure of the current CEO, the Board will appoint an interim CEO in accordance with Article 1. vi) An offer will be subject to submission of a declaration that the candidate has no conflict of interest consistent with organizational policy and in a form as required by the Board, and satisfactory results of a criminal reference check as determined at the sole discretion of the Board. An agreement to support the terms and conditions of employment will be in a form determined by the Board and will be executed by the Board Chair and the candidate accepting the position.

9 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Chief Executive Officer Direction Summary Title: Chief Executive Officer Direction Summary Policy No: II-2 Original Issue Date: 2010 Manual: Board Last Reviewed: November 2016 Revision Date(s): September 2010 March 2012 June 2014 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board s sole official connection to the operational organization, its achievements and conduct will be through the Chief Executive Officer (CEO). The Board provides direction to the CEO in accordance with policies established by the Board. The Board delegates responsibility and authority to the Chief Executive Officer for the management and operation of Quinte Health Care and requires accountability to the Board. The CEO reports to and is accountable to the entire Board of Directors. Direction from the Board to the CEO is relayed and monitored by the Board Chair or in their absence, the Vicechair. The CEO will report to and be responsible to the Quinte Health Care Board for implementing the organization s Strategic Plan, operating and capital plan, and for the day to day operation of the facilities of the organization in a manner consistent with policies established by the Board. The CEO shall not cause or, with the CEO s knowledge, allow any practice, activity, decision or organizational circumstance that is either unlawful, imprudent, or in violation of commonly accepted business and professional ethics.

10 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Chief Executive Officer Job Description Title: Chief Executive Officer Job Description Policy No: II-3 Original Issue Date: 2010 Last Reviewed: November 2016 Manual: Board Revision Date(s): September 2010 March 2012 June 2014 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors POSITION: REPORTS TO: President and Chief Executive Officer QHC Board of Directors POSITION SUMMARY Reporting to the Board of Directors, the President and Chief Executive Officer (CEO) is responsible for the overall operational management of Quinte Health Care (QHC), including delivery of high-quality patient care and ensuring organizational financial health, in accordance with the organization s mission, vision, values, and strategic directions. The President and CEO shall be the administrator within the meaning of the Public Hospitals Act and shall be responsible for compliance with requirements of the Act and the hospital management regulations there under. The CEO and Chief of Staff (COS) will collaborate to achieve the mission, vision, goals and strategic directions of QHC. The President and CEO will provide leadership and guidance in planning and directing the development and implementation of QHC's strategic plan. The President and CEO is responsible for cultivating and maintaining effective relationships between QHC and its internal stakeholders, including the Board, the Foundations, the Auxiliaries, QHC staff, physicians, and volunteers, and its external stakeholders, including the South East LHIN (SE LHIN), Ministry of Health and Long Term Care (MOHLTC), community groups and elected officials. The President and CEO serves as a public face of QHC with the community, media, SE LHIN, MOHLTC, and other government agencies.

11 Key Accountabilities The President and CEO is accountable to the Board of Directors to: Ensure the delivery of the highest standard of care and service to patients and families in a manner consistent with available resources Operate QHC in an efficient, effective, and fiscally responsible manner, in accordance with Board policies, directives, goals and objectives and in accordance with requirements and directions of the SE LHIN and MOHLTC Execute short term and long range plans approved by the Board and funded by the SE LHIN or other approved sources Ensure that QHC is informed of and in receipt of additional funding for new programs, services and innovative practices Ensure that operational and capital expenditures do not exceed budgets approved by the Board Foster and maintain positive relations in the broader health care community, including the SE LHIN, MOHLTC, and health care providers in the public and private sectors of QHC's communities Ensure the Board is kept informed of all significant aspects of QHC management, operations, and quality related issues Ensure compliance with all applicable legislation and directives from regulatory agencies Foster coordination of efforts and activities of QHC staff, medical staff, volunteers and Foundations so that these groups can work collaboratively and cohesively to fulfill QHC's mission, vision, and strategic directions Ensure positive relations in the broader health care community, with the MOHLTC and the SE LHIN, and in the communities that QHC serves Ensure a CEO succession planning process is established

12 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Chief Executive Officer and Chief of Staff Performance Management and Evaluation Title: Chief Executive Officer and Chief of Staff Performance Management and Evaluation Policy No: II-4 Original Issue Date: 2010 Last Reviewed: November 2016 Manual: Board Revision Date(s): September 2010 March 2012 June 2014 March 2015 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board of Directors will establish measurable annual performance expectations in cooperation with the Chief Executive Officer (CEO) and Chief of Staff (COS), assess their performance midyear and annual basis, and determine compensation. The performance review process provides an opportunity to recognize the CEO and COS s levels of performance, to collaboratively develop the organization s priorities for the next fiscal year to present to the Board for approval, and to plan strategies to support the CEO, the COS and the organization s continuing learning and development needs. Guiding Principles: i) Midyear performance evaluations support, reinforce and integrate the achievement of business plan results with individual performance goals. ii) Performance standards, measures and indicators should be established in the Performance Evaluation Plan. iii) Performance commitments and measures should be set at a level which reflects the high level of performance expected. iv) Performance evaluations focus on improving organizational processes, structures and outcomes, on enhancing the CEO and COS s performance and providing recognition for performance against established targets and commitments. v) Executive compensation is directly linked to performance and achievement of key results in specified performance areas.

13 vi) The Performance Evaluation Plans should include reference to the CEO s expectations for senior leaders within the organization, thereby promoting a consistent and continuous approach to performance measurement across the leadership group. vii) The COS is subject to annual reappointment by the Board of Directors via the established credentialing process. viii) The performance reviews involves three key elements: a. Annual goals (midyear and annual review); b. Assessment of identified essential core competencies (annual review only); c. Annual learning and development plan (midyear and annual review). Process: 1. The Ad-hoc Senior Leadership Evaluation and Compensation Committee will jointly develop the midyear and Performance Evaluation Plans with the CEO and COS. Input from the Board Quality of Patient Care Committee will be considered in the development of the plan s identified quality improvement goals. The performance review process shall be the responsibility of the Board Chair, Board Vice-chair and the Chair of the Ad-hoc Senior Leadership Evaluation and Compensation Committee. The midyear performance will be completed following the second quarter. The annual performance review process will commence no later than 30 days following the fiscal year end. 2. The recommended annual Performance Evaluation Plans will be presented to the Board for approval prior to the Board s Annual General Meeting. During the course of the year any amendments will be recommended to the Board by the Ad-hoc Senior Leadership Evaluation and Compensation Committee for approval. 3. Upon Board approval, the quality goals linked to compensation within the annual Performance Management Plans will be posted on the QHC website together with the annual Senior Leadership Executive Compensation Plan. 4. The Ad-hoc Senior Leadership Evaluation and Compensation Committee will review the CEO and COS s performance against the Plan on a midyear basis and provide an update to the Board. 5. On a midyear basis and annually, the CEO and COS are required to complete a selfassessment of their annual performance. 6. All Board members will be requested to provide performance and competency feedback through the completion of the Performance Review evaluation survey for the annual performance review only. The members of the Senior Leadership Team or others as identified by the Ad-hoc Senior Leadership Evaluation and Compensation Committee will also provide performance feedback at the request of the Board Chair. The Vice-chair will then compile the feedback and develop the Performance Review documentation. 7. The Board Chair and Board Vice-chair will communicate the results of the evaluation to the CEO and COS. The Ad-hoc Senior Leadership Evaluation and Compensation Committee will provide a report to the Board on the performance of the CEO and COS relative to the achievement of the goals, the assessment of core competencies and the attainment of the annual Learning and Development Plan.

14 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Compensation for Employees of the Board (CEO and COS) Title: Compensation for Employees of the Board (CEO and COS) Policy No: II-5 Original Issue Date: 2010 Manual: Board Last Reviewed: November 2016 Revision Date(s): September 2010 March 2012 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board is responsible for establishing a fair compensation package for the position of Chief Executive Officer (CEO) and Chief of Staff (COS) in order to: i) Attract and retain highly skilled employees with the requisite competencies. ii) Reward meritorious performance. Compensation paid to the CEO and COS will be set out in an Employment Contract or Service Agreement between Quinte Health Care and the CEO and COS Chief of Staff, which are developed in collaboration with the Board of Quinte Health Care. In establishing the compensation, consideration will be given to market rates paid for like positions within the local geographic area and within the Province, particularly as applicable to the health care sector and at comparator hospitals. Total compensation for the CEO and COS will include the sum of base salary, benefits, and perquisites as applicable. Perquisites will be in keeping with the Broader Public Sector Directives and QHC policy. Adjustments to the compensation will be considered on an annual basis or as per the contract, giving consideration to cost of living changes, market rates, current legislated mandates, and changes in job duties or requirements. Changes to the compensation will only be made upon Board approval, and will generally be made at the time of the annual performance reviews. Changes may occur more frequently, for example to ensure comparability of benefits with other employee groups.

15 The Board, through the Ad-hoc Senior Leadership Evaluation and Compensation Committee, will annually review and approve any contemplated changes in the compensation of both the CEO and COS. The Board Chair and/or Chair of the Ad-hoc Senior Leadership Evaluation and Compensation Committee will report to the Board and advise the CEO and COS of approved changes. Negotiation of Employment Contract for Employees of the Board To ensure appropriate input from Board members regarding the negotiation of the employment contracts for the CEO and COS, a process will be defined which provides the Ad-hoc Senior Leadership Evaluation and Compensation Committee with negotiating parameters. This process will be utilized for contract negotiations between the QHC Board Chair, Ad-hoc Senior Leadership Evaluation and Compensation Committee and the incumbent (either new or existing incumbents). The process will include: i) Chief Human Resources Officer (CHRO) will provide the Board Chair and/or Vice Chair with an overview of the OHA executive salary surveys and/or obtain other relevant and current comparative compensation information. The provincial industry standards for terms within executive contracts and current legislation will also be reviewed. ii) iii) iv) The compensation (salary and benefit) information and other contract parameters shall be discussed by the Ad-hoc Senior Leadership Evaluation and Compensation Committee. This information includes, but is not limited to: term of contract; vacation; renewal and termination clauses; mileage/car allowance or other expense reimbursements. Also to be considered are any known requests or contract parameters identified by the incumbent and results of performance reviews, if any, by the Ad-hoc Senior Leadership Evaluation and Compensation Committee. The Ad-hoc Senior Leadership Evaluation and Compensation Committee will then make a recommendation concerning the parameters by which the contract should be negotiated: maximum compensation amount and length of the term of the contract to the Board of Directors for approval. The Board Chair, together with legal counsel, and the CHRO will negotiate with the incumbent and their legal counsel. v) In order to ensure that independent legal advisement has been received, QHC shall pay the cost of legal fees for the incumbent. vi) In the spirit of transparency, the current Executive contract information for the CEO and COS will be available to the public via the QHC website.

16 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Expense Reimbursement and Travel Policy for Employees of the Board Title: Expense Reimbursement and Travel Policy for Employees of the Board Policy No: II-6 Original Issue Date: 2010 Manual: Board Last Reviewed: November 2016 Revision Date(s): April 2011 March 2012 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Chief Executive Officer (CEO) and Chief of Staff (COS) will be reimbursed and/or compensated for reasonable expenses while carrying out duties for and while traveling on Quinte Health Care related business. Such reimbursement and/or compensation will be consistent with the expense and travel policies and practices for other employee groups within Quinte Health Care. The Board Chair may authorize alternative practices should the need arise. In the event that the terms and conditions within the contract of the CEO and COS and the policies for Quinte Health Care conflict, the terms and conditions of employment will prevail. Given the need for a significant amount of travel between sites and within the region for work activities, the CEO and COS will be eligible for a mileage allowance rather than a flat mileage rate. The Board Chair, on the recommendations of the Chief Financial Officer, will approve allowable expenses and travel claims. The CFO will ensure the expense claims meet the QHC policy and are permissible as per directives from the Ministry of Health and Long-Term Care with respect to the Broader Public Sector Accountability act, The CFO will also ensure CEO and COS expense reports are appropriately posted or disclosed as per Ministry requirements.

17 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Occupational Health and Safety- Accountability Framework Title: Occupational Health and Safety- Accountability Framework Policy No: II-7 Original Issue Date: 2010 Last Reviewed: November 2016 Manual: Board Revision Date(s): September 2010 March 2012 November 2016 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors All members of the organization are expected to demonstrate the commitment towards a safe and healthy work environment by acting in compliance with this policy and the Occupational Health and Safety Act. As per By-Law No. 1 (Article 15.6), the Chief Executive Officer will report to the Board as necessary on matters in respect of the Occupational Health and Safety Program. The Board will receive annual reports from the Chief Executive Officer on the organization s health and safety program through the QHC Board Quality of Patient Care Committee. The reports shall include information about the ability of the organization to meet health and safety requirements, about occupational risk issues, statistical data on staff incidents, and program outcomes. As specified in the By-Law (Article 15.6), the organization s Occupational Health and Safety Program shall include procedures with respect to: i) a safe and healthy work environment in the Corporation; ii) the safe use of substances, equipment and medical devices in the Corporation; iii) safe and healthy work practices in the Corporation; iv) the prevention of accidents to persons on the premises of the Corporation; and v) the elimination of undue risks and the minimizing of hazards inherent in the Corporation environment.

18 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Chief of Staff Job Description Summary Title: Chief of Staff Job Description Summary Policy No: II-8 Original Issue Date: 2010 Last Reviewed: November 2016 Manual: Board Revision Date(s): September 2010 March 2012 June 2014 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors POSITION: Chief of Staff REPORTS TO: QHC Board of Directors POSITION SUMMARY Reporting to the Board of Directors, the Chief of Staff (COS) is responsible for the oversight of the professional staff at Quinte Health Care (QHC), including the supervision of the practice of medicine, dentistry, midwifery and extended class nursing. The COS and President & Chief Executive Officer (CEO) will collaborate to achieve the mission, vision, goals and strategic directions of QHC. As a member of the Senior Leadership Team (SLT), the COS provides medical and professional leadership in the planning and implementation of QHC s strategic plan. Key Accountabilities The COS is accountable to the Board of Directors to: Organizes the professional staff to ensure that the quality of the medical, dental, midwifery, and extended class nursing care given to all patients of QHC is in accordance with policies established by the Board

19 Ensures the establishment and monitoring of the credentialing and disciplining processes for professional staff Ensures that the process regarding credentialing of professional staff is fair and executed in a timely manner Ensures compliance with the Public Hospitals Act (Ontario), Regulations, and Bylaws and policies of QHC, and other relevant legislation with respect to professional staff Oversees the mediation or disciplinary action of the professional staff in collaboration with the Department Chiefs

20 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Chief of Staff Selection and Succession Planning Title: Chief of Staff Selection and Succession Planning Policy No: II-9 Original Issue Date: 2010 Last Reviewed: November 2016 Manual: Board Revision Date(s): September 2010 March 2012 June 2014 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board must ensure that provision is made for continuity of leadership for the organization. The Board will have in place a documented process for succession should the Chief of Staff position become vacant due to sudden loss, resignation, retirement or termination. The succession plan should also specify the process for appointing an interim Chief of Staff, should the Chief of Staff require an extended leave of absence due to personal, health or other reasons. The Board will select and appoint the Chief of Staff as outlined in the QHC Professional Staff By-Laws. Based on best practice, the Chief of Staff is expected to cultivate their successor through internal succession planning. The Chief of Staff is expected to report on this issue annually during the evaluation process. 1. Sudden Vacancy (e.g. death, resignation, termination, extended leave) i) The Chief of Staff will identify to the Chair of the Board in writing at the beginning of each fiscal year which member(s) of the Medical Staff is recommended to fill the role of interim Chief of Staff, if a sudden loss of the Chief of Staff occurs. The appointment of an interim Chief of Staff will be done in conjunction with the CEO and is subject to approval by the Board.

21 2. Planned Vacancy (e.g. retirement) i) The Board will establish a Chief of Staff Search Committee. As per the Professional By-Law (Article 5.01), the membership of a Search Committee shall include: the board chair or designate; two (2) members of the Medical Advisory Committee, one of whom is an officer of the Professional Staff Association; the President and CEO, or his or her delegate; and such other members as the Board deems advisable. ii) The Search Committee may, at its discretion, select a search firm to assist with the process. iii) The Search Committee will interview a short list of candidates and recommend to the Board their candidate of choice. iv) In the event a new Chief of Staff has not been appointed prior to the departure of the current Chief of Staff, the Chief of Staff may be requested to hold office until a successor is appointed. 3. Short Term Vacancy (e.g. out of country vacation) The COS will identify which member of MAC will act in the capacity of Acting COS during the short-term absence. This selection shall be at the discretion of the COS at the time of the absence and may be the same individual as per the 1.0 above or based on availability, another member of the MAC. The COS will advise the CEO and Chair of the Board of the selection prior to departure.

22 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Reporting on Compliance Title: Reporting on Compliance Policy No: II-10 Original Issue Date: 2010 Manual: Board Last Reviewed: November 2016 Revision Date(s): September 2010 November 2016 Section: Part II Provide for Excellent Leadership and Management Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board of Directors understands that, in addition to the standard of care and fiduciary obligations, Directors are subject to duties and liabilities imposed by statute. The Chief Executive Officer will report to the Board on an annual basis regarding Quinte Health Care s compliance with the following items: a) Quinte Health Care is in compliance with all required payroll remittances; Salary, wages and vacation pay owing to employees of Quinte Health Care; b) Remittances for employee income tax deductions, Canada Pension Plan (CPP) and Employment Insurance (EI) premiums and contributions as required by law; c) Remittances for required deductions for payments to non-residents as required by law; d) Workplace Safety and Insurance Board (WSIB)premiums as required by law; e) Employer Health Tax (E) as required by law; f) Harmonized Sales Tax (HST) as required by law. Quinte Health Care is in compliance in all material respects of the Ontario Occupational Health and Safety Act Appropriate steps are being taken to maintain a safe working environment, including the following: a) Joint Health and Safety (JHS) committee is in place; b) JHS committee minutes are maintained; c) JHS committee recommendations and management responses recorded; d) actions are taken where appropriate; e) Safety manuals are up-to-date;

23 f) Hazardous materials are identified; g) Proper maintenance of signage is in place ; and h) Proper procedures are in place for monitoring compliance on an ongoing basis. Quinte Health Care complies with the relevant regulations of the Environmental Protection Act. Liability insurance for Directors and Officers of Quinte Health Care is updated and paid. Coverage is suitable and in accordance with risk and the indemnity amount is sufficient in light of risks.

24 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Quality Improvement and Safety Title: Quality Improvement and Safety Policy No: III-1 Original Issue Date: 2010 Last Reviewed: November 2016 Manual: Board Revision Date(s): September 2010 November 2014 November 2015 November 2016 Section: Part III Ensure Program Quality and Effectiveness Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board of Directors of Quinte Health Care defines quality as the degree of excellence achieved by the organization. The organization will meet or exceed established and evolving standards of quality and patient safety. Quinte Health Care is committed to addressing quality issues and identifying and acting upon opportunities to continuously improve patient care and service delivery. The Board recognizes the importance of monitoring, evaluating and continuously improving the quality of patient care and services. The Board recognizes the importance of the safe delivery of its services, as well as the importance of reducing or preventing the potential for injury or loss to its patients and their, family members, visitors, staff, physicians and volunteers, and damage to or loss of the organization assets. Quinte Health Care is committed to improving the quality of programs and services on a continuous basis. A culture of patient safety is one of the underlying principles in the success of quality improvement. Patient safety has been defined as a patient s freedom from accidental injury when interacting in a healthcare system. Other key principles include timeliness and access, effectiveness and patient-centeredness. Care and management standards are integral to the achievement of this goal. Standards/Quality planning shall align with the Vision, Mission, Values and Corporate Priorities of the organization, and shall support the Business Plan goals and objectives of Quinte Health Care.

25 The Quality of Patient Care Committee carries the delegated responsibility from the Board which is ultimately responsible for oversight and decision making related to quality and safety. The Committee will focus its oversight on the elements described in the Ontario Hospital Association Guide to Good Governance: 1. Address legislative requirements as well as mandatory reporting and accountability (LHIN) requirements. 2. Define Quality of Care with elements that include; a. Patient outcomes and safety b. Patient flow and access to services c. Patient Experience 3. Approving the Hospital Quality Improvement Plan 4. Establishing and Monitoring Performance Reporting 5. Monitoring Quality Risk Management 6. Understanding and Supporting Quality Improvement Efforts a. Education on clinical services b. Patient stories 7. Reviewing Programs (description of services, performance measures, successes, challenges, opportunities) The Board, with the assistance of the Quality of Patient Care Committee, will annually establish performance targets and performance metrics related to quality, and patient and staff safety for monitoring by the Quality of Patient Care Committee. At least quarterly, the Quality of Patient Care Committee will monitor the organization s quality of patient care, and patient and staff safety against the defined performance targets and performance metrics and report to the Board. The Board will discuss issues related to quality of patient care and patient and staff safety as the first item on the Board agenda at every meeting. The Quality of Patient Care Committee will ensure that the quality review and improvement processes, including disclosure, are conducted in accordance with applicable legislation such as the Quality of Care Information Protection Act (2016) and Personal Health Information Protection Act (2004) as amended by the Health Information Protection Act (2016).

26 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Performance Monitoring Title: Performance Monitoring Policy No: III-2 Original Issue Date: 2010 Manual: Board Last Reviewed: November 2016 Revision Date(s): September 2010 November 2014 Section: Part III Ensure Program Quality and Effectiveness Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors There are three main roles for the Board with respect to performance monitoring and assessment: i) Ensuring that management has identified appropriate performance metrics (measures of performance); ii) Monitoring organizational and Board performance against Board approved performance targets and performance metrics; and iii) Ensuring that management has plans in place to address variances from performance targets and overseeing implementation of remediation plans. The Board will ensure that the Chief Executive Officer (CEO) of Quinte Health Care implements an effective performance management system, based on performance metrics for measuring and continuously improving the organization s performance. The Board will approve the targets and performance metrics for monitoring organizational performance in achieving financial, quality and safety targets using best practices and benchmarks. The CEO will establish an annual schedule of specific performance reports to the Board of Directors and appropriate Board Standing Committees. These performance reports are intended to support the Board in its responsibility to monitor and assess the organization s performance related to the established targets and performance metrics.

27 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Risk Management Title: Risk Management Policy No: III-3 Original Issue Date: 2010 Manual: Board Last Reviewed: November 2016 Revision Date(s): September 2010 Section: Part III Ensure Program Quality and Effectiveness Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board must be knowledgeable about risks 1 inherent in hospital operations and ensure that appropriate risk analysis is performed as part of its decision-making. In particular, the Board: i) Oversees management s risk management program; ii) Ensures that appropriate programs and processes are in place to protect against risk; iii) Expects management to identify unusual risks to the organization and ensure that there are plans in place to prevent and manage such risks; iv) Expects management to identify and assess the associated risks to the organization when reviewing and approving resource allocation decisions; v) Anticipates financial needs and potential risks, and develops contingency plans; and vi) Works with the CEO to reduce risks to the organization and promote ongoing quality improvement. The Board of Directors is responsible for ensuring that appropriate risk management practices are in place in the organization, and for reviewing and approving Quinte Health Care s variance 1 A risk is the chance or possibility of danger, loss, or injury. For health services organizations, this can relate to the health and well-being of clients, staff, and the public; property; reputation; environment; organizational functioning, financial stability, market share; and other things of value. Risk management is a systematic process of planning, organizing, leading, and controlling the activities of an organization in order to minimize the effects of risk on that organization, including financial, strategic, operational, and other risks. Canadian Council on Health Services Accreditation. CCHSA s Accreditation Program, 5 th Edition. 2006

28 and risk tolerance levels. Each Board Standing Committee will review the risks related to its mandate. The Chief Executive Officer is accountable for: identifying the principal risks of the organization s business; determining the organization's exposure to risk; and developing and implementing a risk management framework. The Board of Directors of Quinte Health Care will annually monitor and assess the organization s quantification of risks, including asset protection, and how those risks are addressed.

29 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Ethics Title: Ethics Manual: Board Policy No: III-4 Original Issue Date: 2010 Last Reviewed: November 2016 Revision Date(s): September 2010 November 2016 Section: Part III Ensure Program Quality and Effectiveness Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors The Board of Directors will establish the values that serve as the ethical foundation for the organization and the CEO will ensure that the values are imbedded into the orientation and ongoing work of the organization. The Board of Directors will review and approve policies to provide a framework for addressing ethical issues arising from care, education and research at Quinte Health Care. Directors will respect requirements for confidentiality, privacy, and discretion concerning information that is received and issues that are discussed, particularly when of a sensitive nature. Quinte Health Care will operate in compliance with its Articles of Incorporation, By-Laws, governance policies, and relevant legislation.

30 QUINTE HEALTHCARE CORPORATION Disclaimer: Any printed copy of this policy is only as accurate as of the date it was printed: it may not reflect subsequent revisions. Refer to the electronic version of the policy on the Intranet under the Policy and Procedure Manual for the most current policy. Respect for Diversity Title: Respect for Diversity Policy No: III-5 Original Issue Date: 2010 Last Reviewed: November 2016 Manual: Board Revision Date(s): September 2010 November 2015 November 2016 Section: Part III Ensure Program Quality and Effectiveness Policy Lead: Executive Assistant to the Board Approved By: QHC Board of Directors Quinte Health Care is committed to creating a just and satisfying working environment for its employees that is free from abuse and where the dignity and self-esteem of every employee is respected. Quinte Health Care recognizes the dignity and worth of every person and will provide for equal rights and opportunities without discrimination. The organization will be sensitive to potential barriers to accessibility. The organization, as represented by the Board of Directors, staff, physicians, and students value and respect the diversity of its patients and their families, the community, and each other. In addition to abiding by all relevant legislation, the organization will: Establish the principles, processes and responsibilities essential for creating and maintaining a positive work environment consistent with federal and provincial legislation; Promote a climate of understanding and mutual respect for the dignity and worth of every person; Be courteous and tactful in all interactions; Respect the customs and beliefs of individuals consistent with the mission of Quinte Health Care;

31 Strive towards equity and fairness and will work with honesty, integrity, respect and good faith; Promote harmonious relationships with health care partners and community stakeholders; Provide equal rights and opportunities without discrimination; and Be sensitive to potential barriers to accessibility.